Healthcare Value Analysis

Value Analysis in the Pandemic Rear View Mirror: Looking Forward with IP&C and Risk Mitigation in Mind

Editor's note: This column originally appeared in the December 2021 issue of Healthcare Hygiene magazine.

Barbara Strain, founding member and strategic board liaison of the Association of Healthcare Value Analysis Professionals (AHVAP) caught up with Sue Miller, RN, MN, CMRP, CVAHP, to discuss lessons learned from the COVID-19 pandemic with a slant toward infection prevention and control (IP&C). Miller is past president of AHVAP, as well as senior director of enterprise value analysis for Thomas Jefferson University and Jefferson Health.

Barbara Strain (BS): As we look back on the past two years what role did IP&C play in decision making?
Sue Miller (SG): IP&C has been an integral part of Jefferson’s Value Analysis program since our enterprise-wide VA committees were implemented in 2018. Prior to 2020, an IP&C practitioner was assigned to each of our value analysis subcommittees to provide input to the value analysis committee decision-making and to enhance communication both at a local practice level and with other IP&C practitioners across the enterprise. To a general extent this is how IP&C primarily interacts with value analysis on an initiative-by-initiative basis where it seems practical (e.g., PPE apparel, masks, disinfectants, and medical products such as Foley catheters and central lines).
The experience of 2020-21 put value analysis, supply chain and IP&C in the spotlight. In certain key categories, time was not spent qualifying a variety of exam gloves, for example but what were the handful of key characteristics or specifications required for safety versus our ability to actually purchase and receive the goods. Roles shifted to vetting products and navigating feedback from known and unknown manufacturers, distributors, and brokers in real time while the crises unfolded all around them. IP&C assisted in monitoring the FDA Emergency Use Authorizations for products, antigen and antibody testing as well as CDC guidelines on isolation, quarantine, patient-care practice, and Environmental Protection Agency (EPA) disinfectant approvals and advising real-time consultation to ensure staff and patient safety.

BS: How has IP&C transitioned at the executive level at Jefferson Health in 2021?
SM: Value Analysis at Jefferson Health operates as an Enterprise System Executive Steering Committee process and structure, with four enterprise-wide value analysis subcommittees addressing specific clinical areas, such as perioperative services, med-surg commodities and devices, etc. Early in 2021 the organization created the role of enterprise vice president of infection prevention. One of the divisional IPs had be acting in an enterprise advisement role during the pandemic and stepped into the newly created VP role. Value analysis is collaborating with the VP and interpretating the different ways that individual’s contribution to achieving the overall enterprise goals for improving quality and attaining overall value. IP&C thought processes can be anticipated to assist in influencing categories at an enterprise level – home health, telehealth, capital acquisitions, construction planning and materials selection, M&A initiatives, as well as standardization, utilization, and the paving the road value-based care to based care design. This high-level decision making will enhance line of site divisional decision making.

BS: What is the one key critical skill that made the biggest difference during the pandemic and how will it live on post 2021?
SM: Effective communication at the highest level cannot be overrated. A simple example is how to message that there is an opportunity to review a category of product. Like most value analysis professionals, we have had to look for temporary product substitutes due to supply chain disruptions and at times there is a long lead time to getting back to where we need to be with our primary supplier. As an example, in one category, we introduced the concept of what would it look like if we approached this situation as an opportunity to change products to an alternate supplier. This notion made it through the divisions and back to the VP of IP before they had a chance to weigh in making it an awkward if not a potential trust breaking situation. Communication, planning and effective messaging is key!
Additionally, it has been imperative for us to develop a consistent supply interruption management process engaging strategic sourcing, value analysis, procurement and supply chain operations. We hold daily check-in meetings that began in 2020 and which we plan to continue into early 2022 to review back orders, on hand products, substitute products, demand, where we could shift from our enterprise divisions and keep a pulse on operations. The plan is to hardwire this process and pass on the learnings to the divisional level to develop a cadence that makes sense (once or twice a week). It engages everyone in effective communication regardless of the size of the organization.

BS: Keeping the patient at the center of decision making is essential to keep at the center of healthcare delivery. How is Jefferson health assuring this in the face of continued supply chain disruptions?
SM: In light of the need to vet so many alternate products, the needs of our patients and healthcare worker safety and the continual education required by these disruptions we focused the conversation with our medical community around mitigating risk. The four key inputs of risk mitigation are value analysis, clinical integration, strategic sourcing, and logistics. The consistent and open collaboration between the clinical community and the supply chain community has been vital to keep risk in check. We believe so strongly in this approach that the enterprise vice president of infection prevention as well as the enterprise medical director of risk management have both been added to the Enterprise Value Analysis Steering Committee.

BS: Back orders in a variety of healthcare product categories persist and according to some predictions this may last well into 2022. 1 Jefferson Health will be expanding its delivery of care in 2022; how do you foresee this unfolding?
SM: We have used our various divisions within our enterprise to create an internal source of goods. For example, if one division has specific products on hand that others need, we can take advantage of that. By effectively applying our learnings, growth can continue to support those efforts. We have been systematically creating a strong foundation for a resilient future through our enterprise thought leadership while setting a bar of standards to not only meet but to exceed our medical community needs.

Reference:
1. https://www.axios.com/health-care-plagued-by-new-supply-chain-shortages-4366675c-a984-483d-8996-ce70cf8b3656.html:

Healthcare Value Analysis Basics Provide the Grounds for Successfully Navigating the Path and Avoiding Pitfalls

By Mary E. Potter, RN, BS, CVAHP

This column originally appeared in the November 2021 issue of Healthcare Hygiene magazine.

As healthcare value analysis becomes more integral to balancing patient outcomes and financial viability, the need for a standard process for identifying products and services that will meet, but not exceed the requirements is greater than ever. Adhering to the basic principles of healthcare value analysis can help you avoid the pitfalls of product selection.

Pitfall 1: We have a process, but it is not always followed.
When you are experiencing non-compliance to the process, review the basics, have you established a Charter, is there a policy in place, have you created and clearly communicated the expectations to your leaders? More importantly, do you have the support of your executive team? Can you rely on them to remove barriers and support your decisions? Is your process patient centered? Clinicians are more likely to support initiatives that take into consideration the impact on the patient: the product quality, safety, and the impact on patient experience. Take time to make sure everyone is on board.

Pitfall 2: How do we know whether we should move forward with a product evaluation?
This question is all about methodology. A selling point for new products is often the claim that it will “reduce infections.” In the operating room (OR) setting the claim may be that use of the product will “save time.”
To decide whether to approve or reject moving forward with a request, the first step is to identify the need/opportunity. What do you need to achieve that you aren’t able to achieve now? If the claim is reduced infections, meet with your infection preventionist to learn what your current rates are. Do reports support there is an opportunity for improvement? Have you incurred Centers for Medicare & Medicaid Services (CMS) penalties for healthcare-acquired Infections (HAIs)? Your finance representative can help answer this question.
Is there an opportunity to reduce variations in outcomes and reduce costs through standardization and improved contract compliance?
If the claim is to “save time” meet with the subject matter experts (SMEs) to determine whether this objective is realistic. How do your procedural times compare with current industry standards or with you industry peers? Will reducing time result in decreased full-time employees (FTEs) or make scheduling of additional procedures possible?
If the proposed product does not satisfy a legitimate need, do not move forward with the request.

Pitfall 3: How will we know whether a product is acceptable? Should we use a rating system?
Once you determine the need is legitimate, before moving forward, establish the “measurable value.”
SMEs will compile a list of the requirements and characteristics the product/equipment/service must have to be deemed acceptable and identify the measureable value. Is there randomized, controlled, peer reviewed studies supporting improved patient outcomes, improved safety, or cost reduction?
Establishing valid evidence and identifying the product requirements provides you with the tool to evaluate one product or several competitive products. Rating systems often inject preference and subjectivity into the decision process. If you plan to use a rating system there must be clearly defined levels of achievement or acceptability. In place of a rating system, you might choose to simply evaluate each requirement with a “yes” the product satisfies the identified requirement(s) or “no” the product does not satisfy the stated requirement(s). If a product does not satisfy the identified requirements, reject it.

Pitfall 4: What if there is a suspected COI (conflict of interest)?
The Patient Protection and Affordable Care Act of 2010 requires drug, device, and biologic companies to publicly report nearly all gifts or payments they make to physicians beginning in 2013. Beginning on Jan. 1, 2021, reporting entities are now required to collect data about payments made to physicians and teaching hospitals as well physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and anesthesiologist assistants, and certified nurse-midwives. This information is available on the CMS website (https://www.cms.gov/OpenPayments).
Review all randomized, controlled, peer reviewed studies for COI disclosure(s) by the author(s).
Know your organization’s policies to insure you adhere to organizational compliance guidelines, comply with disclosure and confidentiality policies, and can serve as a resource for internal and external customers.

Pitfall 5: When is a trial necessary?
Trusting you have established the need for the proposed products and the product requirements, if there is no randomized controlled, peer-reviewed studies to support the efficacy of the product, you may need to conduct a trial to verify efficacy. A trial is most often requested for a new product/device/pharmaceutical for which there is little or no published information. The identified need and the product requirements and anticipated measurable value will provide the criteria on which you will evaluate the efficacy. Before proceeding with a trial, meet with SMEs to determine either the length of the trial or the number of uses necessary for an adequate determination of efficacy.
Information about existing products currently in use at organizations within your GPO, health system or at regional organizations may provide sufficient evidence of targeted efficacy, safety and patient outcomes in lieu of a trial.

Pitfall 6: What if we are not achieving the measurable value we projected for the approved product/device/pharmaceutical?
Following implementation, it is critically important to ensure you are achieving the measurable value identified. Follow up at three months, six months, one year and annually thereafter to verify you are achieving the projected outcomes. If not, why not? Has old product been removed from inventory? Is additional education required? Determine the root cause and work with SMEs to remedy the situation.

Taking time to apply the discipline of healthcare value analysis can help you and your team avoid these pitfalls. Once you realize the identified value, recognize the contributions made by team members and communicate and celebrate your success.

Mary E. Potter, RN, BS, CVAHP, is an independent value analysis consultant.

 

 

The Role of Value Analysis in Antibiotic Stewardship

By Barbara Strain, MA, SM(ASCP), CVAHP

This column originally appeared in the October 2021 issue of Healthcare Hygiene magazine.

In 2014 the Centers for Disease Control and Prevention (CDC) called upon U.S. hospitals to implement antibiotic stewardship programs using the Core Elements of Hospital Antibiotic Stewardship Programs1 which was subsequently updated in 2019. The seven core elements also form the foundation for antibiotic stewardship accreditation standards from The Joint Commission and DNV-GL. All leaders, physicians, clinicians, and staff working in healthcare settings should be aware of their organization’s antibiotic stewardship efforts and understand the part they can play in supporting these programs.
Hospital antibiotic stewardship programs (ASP) can increase infection cure rates while reducing:
· Treatment failures
· C. difficile infections
· Adverse effects
· Antibiotic resistance
· Hospital costs and lengths of stay

The key stakeholder groups mentioned in the core elements range from hospital epidemiologists, infection prevention and control (IP&C), infectious diseases and other physicians, pharmacists, quality officers and other leaders. Value analysis, although not mentioned in the seven core elements, could be the eighth element.
Value analysis programs are commonly structured into one or more teams of subject matter experts (SMEs) who review current products and services to assure they continue to provide total value to the organization in meeting its clinical and financial goals as well as use proven processes to review new technologies and devices, information technology-based services – such as sensor-based monitoring, artificial intelligence (AI), telehealth and out-of-hospital based solutions.
In 2016 the Centers for Medicare and Medicaid Services (CMS) re-introduced the Conditions of Participation to reflect current standards of practice and to support improvements in quality of care2 by:
· Reducing readmissions
· Reducing barriers to care
· Reducing the incidence of hospital-acquired conditions (including healthcare-associated infections)
· Improving the use of antibiotics (including the potential for reduced antibiotic resistance)
· Addressing workforce shortage issues
· Improving patient protections

The “conditions” significantly changed the landscape of new medical device review that continues today. Suppliers now market new products, equipment and services solutions to value analysis and SMEs primarily using clinical-based evidence to back up claims of reducing HAIs and/or HACs, improving quality, reducing readmissions, and decreasing emergency department visits while assisting hospitals in meeting their antibiotic stewardship goals.

To put these scenarios into perspective some examples include but not limited to medical devices that will prevent the acquisition of infections or assist in treating them effectively without long courses of antibiotics such as:
· Antibiotic or metal impregnated/coated central line catheters, urinary catheters, dressings, stents, bone cement, bed linens, cubical curtains
· Microbiology culture specimen collection devices
· Rapid bacterial identification and antibiotic testing methodologies
· Patient bathing with pH balanced cleansing agents
· Healthcare workers, others alcohol-based hand sanitizers
· Software-based solutions, such as assist in reducing surgical site infections by improving hand hygiene
· Other products and technology

The underlying theme is to prevent HAIs which leads to controlling the use of antibiotics.

No doubt you have seen the cargo ships anchored off the coastal harbors of California and New York waiting to dock and unload countless goods and food. The current wait for a dock spot is two and a half weeks. From there the cargo goes to warehouses where the loads are sorted and sent to their destinations. At that point it maybe a month or two or three before medical supplies reach your care environment. What happens in those in-between-times are backorders. To add to these conditions are the discontinuation of products by suppliers due to a variety of issues from lack of raw materials, low usage, switch of manufacturing lines to other COVID-related needs and business reasons.

To overcome daily needs to assure patients are cared for value analysis professionals work with SMEs and supply chain to identify suitable substitutes meeting key functional criteria, sometimes lining up two or more substitutes depending on availability. Value analysis keeps a watchful eye on the key characteristics of the originally approved product but that is not always realistic. One value analysis director stated that the antibiotic-coated catheter they had standardized to was discontinued; however, the manufacturer offered another one using a different antibiotic. This could create short- and long-term effects on acquiring/treating central line-associated bloodstream infections (CLABSIs) and potentially imbalance an organizations antibiotic stewardship in this one goal.

A paper in JAMA3 reported that of the 1,566 patients that met the study criteria during a six-month period in 2015 showed 55.9 percent of unsupported treatment with antibiotics for the conditions selected. In 2015, the study’s baseline year, only 150 hospitals submitted data to the National Healthcare Safety Network (NHSN), compared to more than 2,000 in 2019 with 49 states performing better on at least two infection types.4

A New Jersey hospital identified a new challenge related to the protocols in settings where patients are being treated for COVID-19.5 The article reported a cluster of 34 hospital-acquired carbapenem-resistant Acinetobacter baumannii (CRAB) cases during a surge in COVID-19 hospitalizations. This investigation highlighted the potential that this multidrug-resistant organism (MDRO) incidence peaked when there was a convergence of shortages in staff, personal protective equipment (PPE) and equipment that prevented standard practices from being followed. The researchers reported that once conventional IP&C strategies were reinstated, the CRAB rate returned to pre-COVID-19 incidence of fewer than two cases per month.

The link between products, equipment, and practice compliance especially during disruptive periods can have an impact on infection prevention and control as well as antibiotic stewardship efforts.

Barbara Strain, MA, SM(ASCP), CVAHP, is an independent healthcare value consultant whose clients range from new emerging and disruptive technology to Fortune 500 companies. Strain honed her expertise over a 40-year career as a healthcare provider across multiple specialties first in clinical laboratory operations, microbiology, disinfection and sterilization, and infection control, then as a value analysis professional. She is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP).

References:
1. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf
2. https://www.cms.gov/newsroom/fact-sheets/cms-issues-proposed-rule-prohibits-discrimination-reduces-hospital-acquired-conditions-and-promotes
3. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2777635
4. https://www.cdc.gov/hai/pdfs/progress-report/2018-Progress-Report-Executive-Summary-H.pdf
5. https://www.cdc.gov/mmwr/volumes/69/wr/mm6948e1.htm

 

 

 

 

Healthcare Value Analysis Professionals at the Infection Prevention Table

By Karen Niven, MS, BSN, RN, CVAHP

Editor's note: This column originally appeared in the September 2021 issue of Healthcare Hygiene magazine.

If we have learned nothing else in the last 18 months amid the pandemic, we have learned the importance of a strong value analysis process that supports our clinical teams, our financial teams, our operational teams, and our leadership teams. Healthcare supply chain has been challenged in 2020-2021 like no other time previously. We must use these painful learnings and events to embrace a value analysis process that is embedded in our organizations. The value analysis process then becomes “the way we do things” instead of “the things we do.” To be best prepared for our next challenges -- and there will be a “next challenge” -- we need to use our learnings and this time to elevate value analysis in our healthcare organizations to have a seat at these table. Value analysis professionals must be at the table -- at the clinical table, at the operational table, at the financial table, at the leadership table, and even at the infection prevention table. So, what does it mean to be at these different tables?

Being at the clinical table means as the clinicians consider the products to provide care for all patients, they use the evidence based clinical value analysis process as a part of their decision. Defined by the Association of Healthcare Value Analysis Professionals (AHVAP), this a “process for evaluating healthcare services for clinical quality and cost effectiveness.” This includes the review and evaluation of clinical evidence as these decisions are under consideration. Value analysis has been described as, “a transforming methodology in healthcare that helps providers select products and services, not on personal preference, but on the best value it brings to the organization and its patients.”

What higher purpose than this do clinicians have to their patients and the care they provide?

Being at the operational table means the involvement of all levels of practitioners, including physicians. This involvement is especially important in the evaluation of new technology and can drive unparalleled value to the new technology assessment. In organizations where physician led value analysis is in place, many of the preference products, such as surgical mesh or surgical energy, can be objectively reviewed and decisions made that supports clinical quality and cost effectiveness. These value analysis discussions are paramount in today’s environment and contributed to outcome excellence and cost containment.

What higher purpose than this do operational leader have to their organizations?
Being at the financial table means the value analysis professional is included in the financial decisions made by the organization. This would include both planning and executing the organization’s financial budgets and plans. A senior leader in my organization said, “We need to evaluate the cost of the care and not dwell on the price of the product.” And what better professional to support the financial teams in that evaluation than the organizations value analysis professionals?

What higher purpose that this do financial leaders have to their organizations and patients?
Being at the leadership table means that in addition to the other organizational leaders, value analysis professionals having a seat at the table allows them to contribute their expertise in conjunction with the AHVAP Value Analysis Statement of Purpose: “Healthcare value analysis contributes to optimal patient outcomes through an evidenced-based systematic approach to review healthcare products, equipment, technology and services. Using recognized practices, organizational resources collaborate to evaluate clinical efficacy, appropriate use and safety for the greatest financial value.”©

What higher purpose than this do leaders have to their organizations and patients?
Being at the infection prevention table means the value analysis professional works with their infection prevention and control professional when evaluating products and make appropriate selection decisions based on sound infection prevention and control (IP&C) guidelines. As a previous surgical services director, I have had the invaluable experience of being included in discussion with IP&C professionals and had the opportunity to invite other perioperative staff as well. In the surgical services practice arena, many times the most valuable voice is the voice of the team in the room. They are the voice of patients who may be unable to speak for themselves. These team members know how to provide the best quality care behind the operating room (OR) door. And this is the voice we need in the value analysis discussions and decisions.

We also must embrace the entire perioperative patient care continuum, including pre-op, intra-op and post-op for patient normothermia. To accomplish this quality patient outcome, our value analysis team should have those patient care areas included in these discussions. As we work across this continuum on the perioperative infection prevention, we need to have full team decisions on the following and explore a value analysis strategy including:
• Analyze current products related to SSI
• Infection prevention/quality working with supply chain to align on product decisions
• Opportunity to combine products for increased value
• Risk share contract solution availability to warrantee prevention

What higher purpose that this do infection prevention leaders have to their organizations and patients?
As the Hippocratic Oath states, “first do no harm.” What a life-changing opportunity value analysis professionals have at this pivotal time in the delivery of quality healthcare. The opportunity to be part of the development, delivery and healthcare changing value analysis process. You have the opportunity to be a part of this journey. So, join value analysis professionals on this amazing industry changing ride.

Karen Niven, MS, BSN, RN, CVAHP, is the Southeast Region director for AHVAP as well as director of Performance Groups for Premier Healthcare Alliance.

Value Analysis Partnership and the Approach With Surgical Services Disruption

By Karen Tucker, MSN, RN, NEA-BC; Gloria Graham DNP, RN, CVAHP; and Heather Waters, MSN, RN

Editor's note: This column originally appeared in the August 2021 issue of Healthcare Hygiene magazine.

Healthcare is recognized for patient care and the outcomes provided by professionals to ensure safe and positive outcomes. To support and maintain positive outcomes for patients and staff, the right supplies and equipment must be available at the right time for the right patient. This area of supply and equipment known as supply chain management/value analysis, is not top-of-mind to caregivers as a potential threat to patient care or daily operations. The lack of equipment or supplies has an impact on operations by delaying care, patient safety, patient outcomes, and ultimately can create waste and harm in the system (Kritchanchai, et al., 2019). Mitigating the risk of patient care disruption is achieved through collaboration with supply chain and value analysis. The Association of Healthcare Value Analysis Professionals (AHVAP) recognizes value analysis as the process that evaluates products to improve patient outcomes through an evidence-based approach while also assessing safety, efficiency and the financial impact.

Collaboration Through the Pandemic
With the last year, healthcare systems and staff recognized how critical the need for equipment and supplies are. Impact of the pandemic and the supply strain highlighted the need to partner with frontline staff, supply chain and value analysis (VA). A basic understanding of this work and collaboration is key to connect the importance to patients and staff. Access and availability to appropriate supplies and equipment for patient care improves workflow and work satisfaction for staff and better outcomes for the patient. Supply chain’s focus in healthcare is to provide appropriate equipment or supply to the patient or staff without causing disruption, or harm to the patient (Emmett, 2019). The need for supplies can be something as simple as gloves and gowns or a critical piece of medical equipment to sustain life for a patient. All supplies within a healthcare system require the right key stakeholders to ensure the process is efficient and the correct supplies are in place from a practice and safety perspective.

Interdisciplinary Approach with Disruption in Supply
A disruption in the supply or equipment process can have negative outcomes. Frontline staff expectations are to have access to supplies and equipment when needed, yet most lack understanding or appreciation of value analysis/supply chain processes. During the COVID-19 pandemic, healthcare systems were faced with a pace of high demand for supplies and equipment coupled with production issues. As a result, hospital leaders and frontline staff quickly realized the importance of supply chain and value analysis impacts and disruptions to staff and patients based on this critical service.

Through the support of VA staff, staff was able to quickly assess and evaluate the needs, assess new products as alternates in conjunction with being mindful of the financial impact. Organizations without a strong VA structure and coordinated team likely experienced even more challenges and struggles to work through as they established contingency plans and set staff at ease with the plans.

Operational Impact
Throughout the last year, the disruption of supplies and equipment was felt by the frontline. All patient care areas were monitored and assessed on an ongoing basis for impact. Some areas of focus during this time were personal protective equipment (PPE) allocations, decrease in volume of specialty supplies, and basic inventory of items causing modification of standard work.

VA staff collaborated with surgical services with PPE allocations due to low inventory during the COVID-19 pandemic for the following items:
• Gowns: Determining the correct level gown and style for wear
• Gloves: Finding alternative manufacturers for the different surgeon needs
• Shoe Covers: Finding the right floor grip/non-slip, universal size and fabric for wear
• Bouffant/skull caps: Finding the correct thickness and size to meet a universal acceptance

As manufacturers attempted to maintain inventory for high-use products, it came with a price to other lower-volume products such as pediatric specialty items. This disruption ultimately led to discontinued items, where the VA staff worked to find alternative items that were presented to the surgical teams. This process was multidisciplinary with VA staff and key stakeholders of the surgical services teams reviewing the product, cost, and outcomes of the alternate product. At times due to patient or special design needs, supplies and alternatives were not available, which created the need for a practice modification provided by the clinicians. Some of these items included:
• Urinary stents
• Cath Lab Quick Fill Straw
• Stapler
• Miscellaneous catheters

The daily perioperative maintenance was also affected during this time, creating taskforce assistance to plan and modify a standardized work process.
• Large sharps containers were added in as a pandemic/critical item
• Disinfectants—weekly par and recycling of containers due to low inventory

There is a value and appreciation for value analysis to work in partnership with frontline operational teams as a critical voice. Through partnering with frontline leaders, both medical and nursing, and other key stakeholders, VA professionals are able to make the best decision for alternate supplies. Any resulting practice changes are decided by the interdisciplinary team, ensuring that any changes are evaluated keeping patient and employee outcomes the priority.

Karen Tucker MSN, RN, NEA-BC, is assistant vice president at Cincinnati Children’s Hospital Medical Center.

Gloria Graham DNP, RN, CVAHP, is a clinical value analyst at Cincinnati Children’s Hospital Medical Center.

Heather Waters MSN, RN, is a clinical value analyst at Cincinnati Children’s Hospital Medical Center.

References:
Emmett D. (2019) Supply chains in healthcare organizations: Lessons learned from recent shortages. Hospital Topics. 97(4), 133-138.

Kritchanchai D, Krichanchai S, Hoeur S and Tan A. (2019) Healthcare supply chain management: Macro and micro perspectives. Log Forum, 15(4), 531-544.

Healthcare Textiles, Laundry and Infection Prevention Programs in Ambulatory Care

By Melanie Miller, RN, CVAHP

Editor's note: This column originally appeared in the July 2021 issue of Healthcare Hygiene magazine.

The recent pandemic begged the question, “Are we doing enough to manage ambulatory care textiles?” Ambulatory surgery centers (ASCs), like healthcare organizations, contract with laundry processors. Laundry processors are expected to follow “hygienically clean” linen standards compliant with the Association of Linen Management (ALM) and TRSA. Additionally, the Association for Professionals in Infection Control and Epidemiology (APIC), has developed standards for ensuring that laundry processors comply with stated recommendations for collecting, transporting, sorting, washing, drying, staging and return delivery to the user.

The pandemic opened up Pandora’s box and the world was suddenly introduced to the concept of disposable and reusable personal protective equipment (PPE) during daily news briefings. Within a few days, the public was notified by news media that PPE and medical commodities were in short supply across the country due to lack of basic raw products and dramatic COVID-19 shutdowns internationally.

Laundry processors were negatively affected by the worldwide pandemic, as were HCOs and service industry businesses alike. When restaurants and service providers were placed on hiatus, laundry processors in both the healthcare and service industries experienced immediate loss of business and revenue. This loss resulted in downstream impacts including, but not limited to, personnel layoffs and laundry closures and shutdowns. If a laundry processor was fortunate to have both service and healthcare organization clientele, it fared better during the pandemic.

Understanding the operational challenges and reusable/disposable product shortfalls throughout the pandemic is important as we begin to dissect infection prevention programs related to textile management in the ambulatory care setting.

Many ASCs were shuttered during the pandemic due to the “hold” on elective procedures. It is estimated that ambulatory centers lost 60 percent of patient throughput at the height of the pandemic.

For those ASCs that remained open, ambulatory service leaders learned quickly that remaining nimble and mid-course correcting when confronted with lack of disposable PPE was key to staying afloat. Leaders quickly contacted their supply chain, purchasing and value analysis colleagues to help them source appropriate reusable PPE.

This was not an easy task. For years, reusable PPE was talked about as a substantive alternative to waste, reducing our carbon footprint and improved sustainability but HCOs were not sold. Fast-forward to disposable shortfalls and drastically reduced allocations without notice. Immediately reusable suppliers went into overdrive trying to produce reusable PPE to meet the new and growing need.

The challenge was which standards were to be followed and would the reusable PPE meet the current published standards. Additionally, would the PPE pass the hygienically clean requirements, including wash cycle validation and certification by recognized testing industry leaders.

Again, ambulatory care leaders looked to supply chain, specifically, value analysis leadership to determine best practice and the required testing and certification to ensure that reusable PPE met and exceeded ANSI/AAMI and Centers for Disease Control and Prevention (CDC) guidelines, including AATCC 42/127, Class I Flammability, Anti-Static and Wash Cycle certification.

Value analysis committees across the country had a new direction sourcing gloves, masks, gowns, respirators, ventilators, and other critical life-saving equipment not in that order. Whereas in the past, a product review might take four to six months, aligning with project management guidelines, communication and collaboration, addressing value analysis methodology, maintaining best business and professional, ethical, and financial practices there simply was not enough time.
At the same time, gray market brokers capitalized on the challenging state of events and went to market with products that did not meet minimum performance standards.

The world of inpatient and ambulatory care was turned upside down in some counties and states due to lack of disposable and reusable supplies, including sheets, towels, patient gowns, isolation gowns and laundry bags.

Leading healthcare laundry and textile organizations jumped to attention and developed webinars and information sharing blogs to help educate HCO staff and healthcare apparel manufacturers. Laundry processors realized that however bleak, downtime was a blessing and instituted new and improved facility cleaning standards, equipment preventive maintenance review and safety training for all staff with an eye to minimizing employee exposure and risk in the workplace.

APIC, through its regional and national leadership forums, helped educate healthcare epidemiologists and value analysis professionals about the most up-to-date standards for disposable and reusable textile management, including PPE and isolation gowns.

When the critical pandemic situation improved, states slowly began reopening. Laundry processors across the country breathed a sigh of relief. They could reestablish their processes and ensure hygienically clean compliance. Many of the laundry processors used the downtime to review their operational policies and procedures to ensure compliance with state directed healthcare textile standards.

Laundry processors knew that going forward their key to future success was engaging the healthcare organizational leaders in inpatient or ambulatory settings to showcase their operational improvements that would result in improved throughput and service post pandemic.

Taking a fresh look at relationship building, many laundry processors leaders reached out to APIC, the Society for Healthcare Epidemiology of America (SHEA) and hospital leaders, and through virtual and in-person teams, reviewed policies and procedures to ensure that the local laundry processors were compliant with hygienically clean standards. Laundry processing leadership recognized the benefits of weekly, monthly, and quarterly check-in with their inpatient and ambulatory clientele.

Reviewing laundry assessment tools resulted in streamlining internal processes and illuminating the partnering benefits with key leaders in linen, value analysis and infection prevention and control (IP&C) in the inpatient and ambulatory setting.
Going forward, a hybrid model appears to be a thoughtful, planful approach to manage ambulatory textiles. Developing service guidelines that encourage patients to wear appropriate clothing to outpatient appointments, imaging procedures and surgical procedures minimizes the need for disposable or reusable linen.

Ambulatory care teams can focus on reusable and disposable textile patient needs that ensure patient dignity, comfort, and best experience. A refreshed approach to ambulatory textile oversight will help manage cost, reduce textile handling, eliminate waste, align with IP&C protocols, and contribute to overall sustainability programs encouraged by healthcare leaders.

Melanie Miller, RN, CVAHP, is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP), and vice president/chief strategy officer of Silver Lining Apparel.

 

 

Infection Prevention and Value Analysis Forge Even Stronger Relationships

By Barbara Strain, MA, CVAHP

Editor's note: This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

Prior to 2020 the participation of infection prevention and control (IP&C) was a key element of successful value analysis (VA) initiatives, but the role took on even more significance because of the COVID-19 pandemic.1 SARS-CoV-2 was a novel virus in the most complete sense. It had not been previously isolated, its mode of transmission was not completely understood, nor were there laboratory tests to detect the presence of the virus itself nor testing for antibody levels to determine immune status. Hot spots were occurring with the rapid surge of symptomatic, sick, and dying patients in healthcare institutions around the world. It became obvious very quickly that there were competing challenges that effected all aspects of the path forward: staff safety, vetting, sourcing, and conserving supplies, and patient care.

To quote an IDN that was interviewed for an Association of Healthcare Value Analysis Professionals (AHVAP) podcast in May 2020, “ensuring the safety of the front-line staff” was essential. To stay abreast of the fast-changing CDC guidelines to assure the most appropriate personal protective equipment (PPE) was available to the clinical and support staff, infection preventionists (IPs) conducted real-time assessments of how care was being provided. It was quickly determined that the usual method of triage and assigning patients to open ICU beds was not an optimal model, so IP&C recommended cohorting patients and staff to dedicated ICUs as the best scenario.

In this newly created, dynamic care environment, staff could don gowns, masks and head coverings, and wear them for longer periods of time without removing, and, in some situations, donned coveralls over basic PPE to conserve use.

Each decision was made based on communication with value analysis professionals (VAPs) who are the clinical connection to hospital supply chain (SC) operations. Before practice was changed or procedures edited, IPs and VAPs conferred on availability of supplies to ensure that new plans could be carried out. SC would provide timely “run rates” indicating how fast high-demand supplies were being used and forecast how long current stock of supplies would last as well as when additional stock would arrive. Using their knowledge, skills, and abilities IPs and VAPs created lists of the key characteristics of the high-demand supplies which reduced the time to locate best-fit equivalents to ensure uninterrupted care.

When it became clear that the global supply of non-powered respirators/N95 masks were not keeping up with demand and were met with fit-testing constraints, the CDC decided to allow either third-party vendors to provide reprocessing services of these masks or allow hospitals to perform reprocessing on site by specific approved methodologies. VAPs gathered the information to determine which option(s) had the shortest implementation timeline for teams led by IPs along with staff from biomedical engineering and facilities, and executive leadership could make easy-to-operationalize, safe decisions.

Other conservation practices included IP&C approving the use of extra-long IV-intravenous tubing connected to the patient to allow respective IV pumps to function outside the room. This measure decreased the number of times a fully donned nurse had to go into a patient’s room to monitor and adjust the settings.

Even before it was confirmed by CDC and NIH that patients were highly contagious, IPs, chief medical officers and chief nursing officers instituted negative-pressure room policies. With the assistance of facilities management professionals, plans were put in place to convert regular patient rooms, emergency department holding rooms, and other appropriate care-spaces into negative-pressure conditions where physically possible. This kept contagious viral particles from entering non-care areas or areas where non-healthcare workers or those not wearing powered or non-powered N95 masks were present.

Prior to the availability of certain drugs, convalescent serum or other treatments were available for patients whose lung capacity and breathing conditions deteriorated, a large percentage were put on ventilators.2 In most hospitals there are fleet of ventilators for a normal level of patient need, plus a reserve amount for unexpected circumstances -- but it is not equipped to handle the high, long-lasting surge caused by COVID-19. VAPs were called into action to vet a new set of criteria for ventilator tubing and hoses as well as connectors for their own fleets of ventilators and for other models that may have been rented or purchased. Some hospitals that had both a space constraint and ventilator shortage adapted what the FDA referred to as “multiplexing ventilator tubing connectors, also known as ventilator splitters, in situations in which no alternatives for invasive ventilatory support are available,” and provide a considerations list that health care providers and facilities should review.3

In extreme situations, patients were placed on ECMO-extracorporeal membrane oxygenation treatment, where oxygen is delivered directly to the patient’s bloodstream to bring relief to breathing impairment. Hospitals with specially trained staff and ECMO equipment to support such treatments put additional strain on capacity to use this practice as patient demand rose above normal. Ventilators and ECMO come with their own set of issues that IP&C monitored closely along with anesthesiology and respiratory therapy to assure that precautions were in place to prevent development of ventilator-associated pneumonia, bloodstream and other infections.

Since the number of COVID-19 cases have ceded to lower, manageable levels, hospitals have begun to open their care services to pre-2020 conditions. Lessons learned from the pandemic informed how the delivery of care can be effective through:
· Reviewing and updating emergency operations, infection prevention and control, and institutional & departmental policies,
· Creating a response handbook based on critical triggers which include but are not limited to:
- Monitor CDC, WHO and other global health watchdogs by Emergency Preparedness Committees and IP&C
- Establish a global raw materials, work-in-progress and finished goods alert system and report dashboard
- List key departments – such as IP&C, VAP, SC -- who should be notified based on mutually agreed upon on-hand and available-to-purchase product thresholds
· Identifying top product needs in incident categories and develop a list of key characteristics for each product to facilitate quick decision-making. For example, for air born contagion: non-powered or powered respirators, face shields, protective gowns, oxygen masks/tubing, list of key characteristics each product type
· Adopting the communication style and methods that worked during Covid19 as your organization’s everyday method.

The COVID-19 pandemic has taught us many lessons but the importance of interprofessional relationships has been undeniably one of the best learned.

Barbara Strain, MA, CVAHP, is an independent healthcare value consultant whose clients range from new emerging and disruptive technology to Fortune 500 companies. Strain honed her expertise over a 40-year career as a healthcare provider across multiple specialties first in clinical laboratory operations, microbiology, disinfection and sterilization, and infection control, then as a value analysis professional. She is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP).

References:
1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html#IPC-priorities
2. https://www.npr.org/sections/health-shots/2020/04/02/826105278/ventilators-are-no-panacea-for-critically-ill-covid-19-patients
3. https://www.fda.gov/medical-devices/letters-health-care-providers/using-ventilator-splitters-during-covid-19-pandemic-letter-health-care-providers